1
|
Sekine S, Pinnow EE, Wu E, Kurtzig R, Hall M, Dal Pan GJ. Assessment of the impact of scheduled postmarketing safety summary analyses on regulatory actions. Clin Pharmacol Ther 2016; 100:102-8. [PMID: 26853718 DOI: 10.1002/cpt.346] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/31/2016] [Indexed: 02/04/2023]
Abstract
In addition to standard postmarketing drug safety monitoring, Section 915 of the Food and Drug Administration Amendments Act of 2007 (FDAAA) requires the US Food and Drug Administration (FDA) to conduct a summary analysis of adverse event reports to identify risks of a drug or biologic product 18 months after product approval, or after 10,000 patients have used the product, whichever is later. We assessed the extent to which these analyses identified new safety signals and resultant safety-related label changes. Among 458 newly approved products, 300 were the subjects of a scheduled analysis; a new safety signal that resulted in a safety-related label change was found for 11 of these products. Less than 2% of 713 safety-related label changes were based on the scheduled analyses. Our study suggests that the safety summary analyses provide only marginal value over other pharmacovigilance activities.
Collapse
Affiliation(s)
- S Sekine
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA.,Office of International Programs, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan
| | - E E Pinnow
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - E Wu
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - R Kurtzig
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - M Hall
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - G J Dal Pan
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| |
Collapse
|
2
|
Wei S, Loyo-Berríos NI, Haigney MC, Cheng H, Pinnow EE, Mitchell KR, Beachy JH, Woodward AM, Wang Y, Curtis JP, Marinac-Dabic D. Elevated B-Type Natriuretic Peptide Is Associated With Increased In-Hospital Mortality or Cardiac Arrest in Patients Undergoing Implantable Cardioverter-Defibrillator Implantation. Circ Cardiovasc Qual Outcomes 2011; 4:346-54. [DOI: 10.1161/circoutcomes.110.943621] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shaokui Wei
- From the Division of Epidemiology (S.W., N.I.L.-B., H.C., E.E.P., D.M.D.), Office of Surveillance and Biometrics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD; the Division of Cardiology (M.C.P.H.), Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; the American College of Cardiology (K.R.M., J.H.B., A.M.W.), Washington, DC; and the Section of Cardiovascular Medicine (Y.W., J.P.C.), Department of Internal
| | - Nilsa I. Loyo-Berríos
- From the Division of Epidemiology (S.W., N.I.L.-B., H.C., E.E.P., D.M.D.), Office of Surveillance and Biometrics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD; the Division of Cardiology (M.C.P.H.), Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; the American College of Cardiology (K.R.M., J.H.B., A.M.W.), Washington, DC; and the Section of Cardiovascular Medicine (Y.W., J.P.C.), Department of Internal
| | - Mark C.P. Haigney
- From the Division of Epidemiology (S.W., N.I.L.-B., H.C., E.E.P., D.M.D.), Office of Surveillance and Biometrics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD; the Division of Cardiology (M.C.P.H.), Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; the American College of Cardiology (K.R.M., J.H.B., A.M.W.), Washington, DC; and the Section of Cardiovascular Medicine (Y.W., J.P.C.), Department of Internal
| | - Hong Cheng
- From the Division of Epidemiology (S.W., N.I.L.-B., H.C., E.E.P., D.M.D.), Office of Surveillance and Biometrics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD; the Division of Cardiology (M.C.P.H.), Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; the American College of Cardiology (K.R.M., J.H.B., A.M.W.), Washington, DC; and the Section of Cardiovascular Medicine (Y.W., J.P.C.), Department of Internal
| | - Ellen E. Pinnow
- From the Division of Epidemiology (S.W., N.I.L.-B., H.C., E.E.P., D.M.D.), Office of Surveillance and Biometrics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD; the Division of Cardiology (M.C.P.H.), Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; the American College of Cardiology (K.R.M., J.H.B., A.M.W.), Washington, DC; and the Section of Cardiovascular Medicine (Y.W., J.P.C.), Department of Internal
| | - Kristi R. Mitchell
- From the Division of Epidemiology (S.W., N.I.L.-B., H.C., E.E.P., D.M.D.), Office of Surveillance and Biometrics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD; the Division of Cardiology (M.C.P.H.), Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; the American College of Cardiology (K.R.M., J.H.B., A.M.W.), Washington, DC; and the Section of Cardiovascular Medicine (Y.W., J.P.C.), Department of Internal
| | - James H. Beachy
- From the Division of Epidemiology (S.W., N.I.L.-B., H.C., E.E.P., D.M.D.), Office of Surveillance and Biometrics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD; the Division of Cardiology (M.C.P.H.), Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; the American College of Cardiology (K.R.M., J.H.B., A.M.W.), Washington, DC; and the Section of Cardiovascular Medicine (Y.W., J.P.C.), Department of Internal
| | - Albert M. Woodward
- From the Division of Epidemiology (S.W., N.I.L.-B., H.C., E.E.P., D.M.D.), Office of Surveillance and Biometrics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD; the Division of Cardiology (M.C.P.H.), Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; the American College of Cardiology (K.R.M., J.H.B., A.M.W.), Washington, DC; and the Section of Cardiovascular Medicine (Y.W., J.P.C.), Department of Internal
| | - Yongfei Wang
- From the Division of Epidemiology (S.W., N.I.L.-B., H.C., E.E.P., D.M.D.), Office of Surveillance and Biometrics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD; the Division of Cardiology (M.C.P.H.), Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; the American College of Cardiology (K.R.M., J.H.B., A.M.W.), Washington, DC; and the Section of Cardiovascular Medicine (Y.W., J.P.C.), Department of Internal
| | - Jeptha P. Curtis
- From the Division of Epidemiology (S.W., N.I.L.-B., H.C., E.E.P., D.M.D.), Office of Surveillance and Biometrics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD; the Division of Cardiology (M.C.P.H.), Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; the American College of Cardiology (K.R.M., J.H.B., A.M.W.), Washington, DC; and the Section of Cardiovascular Medicine (Y.W., J.P.C.), Department of Internal
| | - Danica Marinac-Dabic
- From the Division of Epidemiology (S.W., N.I.L.-B., H.C., E.E.P., D.M.D.), Office of Surveillance and Biometrics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD; the Division of Cardiology (M.C.P.H.), Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; the American College of Cardiology (K.R.M., J.H.B., A.M.W.), Washington, DC; and the Section of Cardiovascular Medicine (Y.W., J.P.C.), Department of Internal
| |
Collapse
|
3
|
Yang Y, Carlin AS, Faustino PJ, Motta MIP, Hamad ML, He R, Watanuki Y, Pinnow EE, Khan MA. Participation of women in clinical trials for new drugs approved by the food and drug administration in 2000-2002. J Womens Health (Larchmt) 2009; 18:303-10. [PMID: 19243271 DOI: 10.1089/jwh.2008.0971] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE This study aimed to track the inclusion of women in clinical trials for new drugs approved by the Food and Drug Administration (FDA) between 2000 and 2002 and to evaluate the extent of analyses by sex. METHODS Data were extracted from FDA reviewers' reports, summaries of clinical trials in New Drug Applications (NDAs), and product labeling and organized into a Microsoft Access database. The information collected includes subject enrollment by sex per clinical phase and sex differences in pharmacokinetics, safety, and efficacy as determined by either sponsors or reviewers. RESULTS There were 67 New Molecular Entities (NMEs) approved by the FDA between 2000 and 2002. A total of 397,825 subjects were enrolled in 2,323 clinical trials. If 9 sex-specific NMEs are excluded, 297,697 subjects were enrolled in 1,974 clinical trials. Forty-seven percent of participants were male, 49% were female, and 4% of subjects were not specified. Of the 58 sex-nonspecific products in the study, 71% (41 of 58) of sex analyses were performed either by the sponsor or FDA reviewers. Twenty-five NMEs were found to have sex differences in pharmacokinetics, efficacy or adverse events. However, no recommendation was made to adjust dosage based on sex differences. CONCLUSIONS The percentages of women and men participating in clinical trials varied by year, phase, and product type. However, the overall participation by women and men was comparable, suggesting an improvement in including more women in clinical trials when compared with the previous FDA study evaluating women's participation from 1995 through 1999. As with the previous study, however, a significant underrepresentation of women in early phase trials and in certain areas, such as cardiovascular products, was observed and continues to be an issue of concern. Lack of appropriate analyses by sex should also be noted as an issue of concern.
Collapse
Affiliation(s)
- Yongsheng Yang
- Food and Drug Administration, Center for Drug Evaluation and Research, Silver Spring, Maryland 20993, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Lindsay J, Grasa G, Pinnow EE, Plude G, Pichard AD. Procedural results of coronary angioplasty but not late mortality have improved in patients with depressed left ventricular function. Clin Cardiol 2009; 22:533-6. [PMID: 10492843 PMCID: PMC6655505 DOI: 10.1002/clc.4960220809] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Published experience with coronary angioplasty in patients with severely depressed left ventricular (LV) ejection fraction indicates that procedural complications are more frequent in such patients than in those with normal or near normal LV function. Although the immediate outcomes of transcatheter revascularization in unselected populations have improved substantially since the procedures upon which these reports were based were performed, outcomes with this subset of patients has not been recently reviewed. HYPOTHESIS This study was undertaken to document the results of the application of current transcatheter technology to this patient subset. METHODS We analyzed data from 194 consecutive patients with a visually estimated LV ejection fraction < 30%, who underwent coronary angioplasty in this institution between January 1, 1995, and April 30, 1996, and compared their outcomes with those of 1,390 patients with normal LV function treated concurrently. RESULTS Angiographic success in the two groups was similar. The hospital mortality of the patients with low ejection fraction was higher (2.6 vs. 0.6%, p = 0.02) than in concurrently treated patients with normal LV function. Other procedural complications were no more frequent than in such patients. Late mortality in patients with low ejection fraction was 16%, a similar value to that in older reports. CONCLUSION Compared with older reports, current hospital outcomes of coronary angioplasty are improved in patients with severely depressed LV function. Unfortunately, late outcomes are not demonstrably better.
Collapse
Affiliation(s)
- J Lindsay
- Section of Cardiology, Washington Hospital Center, Washington, D.C. 20010, USA
| | | | | | | | | |
Collapse
|
5
|
Kuchulakanti P, Wolfram R, Torguson R, Rha SW, Cheneau E, Clavijo L, Chu WW, Pinnow EE, Canos D, Satler LF, Suddath WO, Pichard AD, Kent KM, Waksman R. Bivalirudin compared with IIb/IIIa inhibitors in patients with in-stent restenosis undergoing intracoronary brachytherapy. Cardiovascular Revascularization Medicine 2005; 6:154-9. [PMID: 16326376 DOI: 10.1016/j.carrev.2005.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Accepted: 06/23/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Bivalirudin is replacing heparin in percutaneous coronary interventions (PCIs), including vascular brachytherapy (VBT). The aim of the study was to compare bivalirudin with eptifibatide in patients with in-stent restenosis (ISR) undergoing PCI and VBT. METHODS One hundred forty-four patients treated with bivalirudin as a single antithrombotic agent were compared with 150 patients treated with eptifibatide. Bivalirudin as a bolus of 0.75 mg/kg followed by 1.75 mg/kg/h infusion until the end of the procedure, and eptifibatide as a double bolus of 180 microg/kg followed by 2 microg/kg/min infusion for 18 h after the procedure were used. The main outcome measures were in-hospital events and 30-day clinical outcomes. RESULTS Baseline clinical characteristics were similar except that patients in the eptifibatide group were younger (P=.02) and had more saphenous vein graft lesions (P<.001). Patients in the bivalirudin group had a higher number of lesions in the right coronary artery (P<.001) and a higher number of vessels treated (P<.001). Postprocedure creatinine phosphokinase (CPK)-MB levels were significantly lower in the bivalirudin group (P<.03). In-hospital events showed significantly less minor bleeding (P=.01) and a trend toward lower major bleeding and major adverse cardiac events (MACE) in the bivalirudin group (P=.06). Thirty-day outcomes showed a significantly lower incidence of non-Q-wave myocardial infarction (MI) in the bivalirudin group (P=.004). CONCLUSION Bivalirudin, as a single antithrombotic agent during PCI and VBT, is associated with significantly lower postprocedural CPK-MB elevation, minor bleeding complications, 30-day non-Q-wave MI rates, and a trend toward lower major bleeding and in-hospital MACE when compared with eptifibatide.
Collapse
Affiliation(s)
- Pramod Kuchulakanti
- Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington DC 20010, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Kuchulakanti P, Wolfram R, Torguson R, Rha SW, Cheneau E, Pinnow EE, Canos D, Satler LF, Pichard AD, Kent KM, Waksman R. Brachytherapy and bivalirudin evaluation study. Am Heart J 2005; 150:832-7. [PMID: 16209990 DOI: 10.1016/j.ahj.2004.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2004] [Accepted: 11/17/2004] [Indexed: 11/28/2022]
Abstract
BACKGROUND Bivalirudin is shown to be a competent substitute for heparin in percutaneous coronary intervention (PCI). The safety and efficacy of bivalirudin in patients undergoing PCI and vascular brachytherapy (VBT) are not known. This study aimed to assess the safety and efficacy of bivalirudin as a single antithrombotic agent in patients undergoing PCI and VBT. METHODS A total of 152 patients enrolled in the Brachytherapy and Bivalirudin Evaluation Study underwent PCI and VBT with either gamma (n = 8) or beta radiation (n = 144). The main outcome measures were in-hospital events and 30-day clinical outcomes. All patients were treated with bivalirudin (0.75 mg/kg bolus and 1.75 mg/kg per hour infusion for beta radiation, 1 mg/kg bolus and 2.5 mg/kg per hour infusion for gamma radiation) as a single antithrombotic agent during the entire procedure. RESULTS Baseline clinical and angiographic characteristics were similar between the 2 groups. More than 90% of the patients received beta radiation. In-hospital events showed a higher prevalence of acute procedural intracoronary thrombosis in patients treated with gamma- vs beta radiation (25% vs. 0.7%, P < .001). Thirty-day outcomes including death, Q-wave, and non-Q-wave myocardial infarctions, subacute stent thromboses, and repeat revascularizations were similar in both groups. CONCLUSION Bivalirudin, as a single antithrombotic agent during PCI and VBT with beta emitters, may be used safely, but its use in the setting of PCI and gamma radiation may not be acceptable due to an increased incidence of acute procedural intracoronary thrombosis.
Collapse
Affiliation(s)
- Pramod Kuchulakanti
- Division of Cardiology, Department of Internal Medicine, Washington Hospital Center, Washington, DC 20010, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Rha SW, Kuchulakanti P, Ajani AE, Cheneau E, Pinnow EE, Canos DA, Torguson R, Pichard AD, Satler LF, Kent KM, Ramee S, Teirstein P, Lindsay J, Waksman R. Three-year follow-up after intravascular γ-radiation for in-stent restenosis in saphenous vein grafts. Catheter Cardiovasc Interv 2005; 65:257-62. [PMID: 15864805 DOI: 10.1002/ccd.20372] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The Washington Radiation for In-Stent Restenosis Trial in Saphenous Vein Grafts (SVG WRIST) demonstrated safety and efficacy of intravascular radiation therapy (IRT) for the treatment of in-stent restenosis (ISR) in SVG at 12 months. In this study, we aimed to examine whether the safety and efficacy of IRT is durable up to 36 months. One hundred twenty patients with diffuse ISR in SVG underwent balloon angioplasty, laser or atherectomy ablation, and/or additional stenting. After successful intervention, patients were randomly assigned in a double-blind fashion to intravascular treatment with a ribbon containing either iridium (Ir)-192 (n = 60) or nonradioactive seeds (n = 60). The prescribed dose at 2 mm from the source was either 14 or 15 Gy in vessels 2.5-4.0 mm or 18 Gy in vessels > 4.0 mm in diameter. At 36 months, target lesion revascularization (TLR; 43% vs. 66%; P = 0.02) and target lesion revascularization-major adverse cardiac event (TLR-MACE; 49% vs. 71%; P = 0.02) rates continued to be lower in the IRT group, but both target vessel revascularization (TVR; 59% vs. 71%; P = 0.17) and TVR-MACE (63% vs. 77%; P = 0.11) rates were not. In SVG WRIST, patients with ISR treated with IRT had a marked reduction in the need for repeat TLR at 36 months, with sustained clinical benefit at 3 years despite late recurrences, which were more pronounced in the radiation group.
Collapse
Affiliation(s)
- Seung-Woon Rha
- Division of Cardiology, Washington Hospital Center, Washington, District of Columbia 20010, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Chu WW, Rha SW, Kuchulakanti PK, Cheneau E, Torguson R, Pakala R, Pinnow EE, Pichard AD, Satler LF, Kent KM, Lindsay J, Waksman R. Selective versus exclusive use of sirolimus-eluting stent implantation in multivessel coronary artery disease. Catheter Cardiovasc Interv 2005; 65:473-7. [PMID: 15973656 DOI: 10.1002/ccd.20431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Sirolimus-eluting stents (SESs; Cypher) have demonstrated a significant reduction in restenosis rates when compared to bare metal stents (BMSs). The purpose of this study was to evaluate the strategy of exclusive use of two SESs versus the combination of one BMS and one SES for two-vessel coronary artery disease (CAD). It was found that the selective use of one SES combined with one BMS in patients undergoing percutaneous coronary intervention that requires more than one stent is safe, feasible, and associated with favorable procedural, 30-day, and 6-month clinical outcomes when compared to the exclusive use of SESs.
Collapse
Affiliation(s)
- William W Chu
- Division of Cardiology, Washington Hospital Center, Washington, DC 20010, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Wolfram R, Cheneau E, Mintz GS, Pichard AD, Satler LF, Kent KM, Suddath WO, Pinnow EE, Waksman R. Angiographic and clinical outcomes of late total occlusion versus treatment failure without late total occlusion in patients after intracoronary radiation therapy for in-stent restenosis. Am J Cardiol 2004; 94:1551-4. [PMID: 15589015 DOI: 10.1016/j.amjcard.2004.08.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2004] [Accepted: 08/05/2004] [Indexed: 11/19/2022]
Abstract
This study aimed to compare the outcomes of patients with late total occlusion (LTO) versus patients with recurrence in the absence of LTO after intracoronary radiation therapy for in-stent restenosis. LTO, especially in the context of acute myocardial infarction, after intracoronary radiation therapy for in-stent restenosis, is associated with negative clinical outcomes after 6 and 12 months compared with in-stent restenosis without LTO.
Collapse
Affiliation(s)
- Roswitha Wolfram
- Cardiovascular Research Institute, Division of Cardiology, Washington Hospital Center, DC, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Kuchulakanti P, Rha SW, Satler LF, Suddath WO, Pichard AD, Kent KM, Weissman NJ, Cheneau E, Pakala R, Canos DA, Pinnow EE, Waksman R. Safety of percutaneous coronary intervention alone in symptomatic patients with moderate and severe valvular aortic stenosis and coexisting coronary artery disease: analysis of results in 56 patients. J Invasive Cardiol 2004; 16:688-91. [PMID: 15596870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Whether percutaneous coronary intervention (PCI) alone is safe in patients with moderate or severe aortic stenosis (AS) and coexisting coronary artery disease (CAD), and whether aortic valve replacement (AVR) can be deferred in patients with moderate AS by undergoing PCI alone is not known. We conducted a retrospective study of surgically inoperable patients with AS who underwent PCI (moderate AS, n = 28; and severe AS, n = 28) and compared to those with AVR (n = 55). The clinical characteristics, procedural complications, in-hospital and long-term clinical outcomes of PCI were compared. Baseline and procedural characteristics were similar except that lower age, hypertension, and renal impairment were seen in the AVR group. In-hospital complications were comparable among the 3 groups. Six-month and 1-year rates of myocardial infarction (MI), non-Q-wave MI, death and out-of-hospital death were similar between AVR and moderate AS patients (p = NS) and significantly high (p < 0.04) in patients with severe AS. On multivariate analysis, severe AS was the only significant predictor of 6-month and 1-year mortality. Our study suggests that PCI is safe in patients with moderate AS and coexisting CAD but is associated with poor outcomes in patients with severe AS.
Collapse
Affiliation(s)
- Pramod Kuchulakanti
- Division of Cardiology, Washington Hospital Center, 110 Irving Street, N.W., Suite 4B-1, Washington, DC 20010, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Hurst W, Sandler LL, Pinnow EE, Lindsay J. The accuracy of electrocardiographic Q waves for the detection of prior myocardial infarction as assessed by a novel standard of reference. Clin Cardiol 2004; 27:97-100. [PMID: 14979630 PMCID: PMC6654065 DOI: 10.1002/clc.4960270212] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The electrocardiogram (ECG) is valuable for the identification of prior myocardial infarction (MI) in individuals participating in epidemiologic studies or undergoing screening examinations. Although the Minnesota Code, a set of criteria for the interpretation of ECGs in such situations, is commonly used to identify MI in these settings, its accuracy is incompletely understood. HYPOTHESIS We sought to test the accuracy of the Minnesota Code Q and QS criteria for MI against a new standard of reference, the presence of a perfusion defect on a resting myocardial scintigraphic image. METHODS The resting myocardial scintigrams of all patients studied in our nuclear cardiology laboratory during 7 consecutive months were screened for the presence of perfusion defects. For each patient with such a defect, two individuals examined on the same day, who had no perfusion defect, were selected as controls. Electrocardiograms recorded within 30 days of the scintigraphy were read blindly by two of the authors using the Minnesota Code criteria for Q or QS waves indicative of MI. RESULTS For 214 patients selected on the basis of their scintigraphic findings, a satisfactory ECG recorded within a month of the scintigraphy was also available. The overall sensitivity of the Q or QS criteria was 0.58 and the specificity was 0.75. As might be expected when only the most stringent criteria were applied, sensitivity was least and the specificity best. CONCLUSIONS As in previous studies, in which necropsy material served as the standard of reference, sensitivity of the Q and QS criteria contained in the Minnesota Code is relatively modest and specificity is reasonable but not outstanding.
Collapse
Affiliation(s)
- Willis Hurst
- Division of Cardiology of the Washington Hospital Center, Washington, D C., USA
| | - Leonard L. Sandler
- Division of Cardiology of the Washington Hospital Center, Washington, D C., USA
| | - Ellen E. Pinnow
- Division of Cardiology of the Washington Hospital Center, Washington, D C., USA
| | - Joseph Lindsay
- Division of Cardiology of the Washington Hospital Center, Washington, D C., USA
| |
Collapse
|
12
|
Kuchulakanti P, Rha SW, Satler LF, Suddath WO, Pichard AD, Kent KM, Pakala R, Canos DA, Pinnow EE, Waksman R. Impact of major side branch on periprocedural enzyme elevation and long-term outcome in patients undergoing percutaneous coronary intervention and brachytherapy for in-stent restenosis. Am J Cardiol 2004; 93:1394-7, A9. [PMID: 15165922 DOI: 10.1016/j.amjcard.2004.02.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2003] [Revised: 02/09/2004] [Accepted: 02/09/2004] [Indexed: 11/18/2022]
Abstract
Side branch occlusion is 1 mechanism for the increase of creatine phosphokinase-MB after percutaneous coronary intervention and is associated with long-term adverse events. We studied 248 patients who underwent brachytherapy for in-stent restenosis with and without side branches, compared levels of creatine phosphokinase-MB with procedural, in-hospital, and long-term clinical outcomes, and found that patients with side branches have increased levels of creatine phosphokinase-MB after percutaneous coronary intervention and higher rates of restenosis, target vessel, and target lesion revascularization at 6-month follow-up.
Collapse
Affiliation(s)
- Pramod Kuchulakanti
- Division of Cardiology, Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Rha SW, Waksman R, Aggrey G, GebreEyesus A, Torguson R, Nandalur M, Kuchulakanti PK, Pakala R, Pinnow EE, Lindsay J. 1063-61 Angiomax versus heparin as an antithrombotic agent in patients undergoing percutaneous coronary intervention in saphenous vein bypass grafts. J Am Coll Cardiol 2004. [DOI: 10.1016/s0735-1097(04)90218-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
14
|
Wolfram R, Mintz G, Weissman NJ, Kuchulakanti PK, Rha SW, Cheneau E, Aggrey G, Abbott MC, Gevorkian N, Pinnow EE, Waksman R. 1080-64 Late total occlusion versus treatment failure without late thrombotic occlusion in patients after intracoronary radiation: Angiographic and clinical outcomes. J Am Coll Cardiol 2004. [DOI: 10.1016/s0735-1097(04)90241-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
15
|
Leborgne L, Cheneau E, Wolfram R, Pinnow EE, Canos DA, Pichard AD, Suddath WO, Satler LF, Lindsay J, Waksman R. Comparison of baseline characteristics and one-year outcomes between African-Americans and Caucasians undergoing percutaneous coronary intervention. Am J Cardiol 2004; 93:389-93. [PMID: 14969608 DOI: 10.1016/j.amjcard.2003.10.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2003] [Revised: 10/14/2003] [Accepted: 10/14/2003] [Indexed: 11/19/2022]
Abstract
The objectives of this study were to determine whether there are race-based differences in baseline characteristics and in short- or long-term outcomes after percutaneous coronary intervention (PCI). African-Americans have a higher incidence of coronary artery disease but are less likely to undergo coronary revascularization than Caucasians. Little is known about the profiles and outcomes of African-Americans who undergo PCI. Consecutive series of 1,268 African-Americans and 10,561 Caucasians with symptomatic coronary artery disease who underwent PCI between January 1994 and June 2001 were analyzed. Patients hospitalized for acute myocardial infarction were excluded. African-Americans were older, were more likely to be women, and had more co-morbid baseline conditions compared with Caucasians. Preprocedure lesion characteristics were similar with regard to vessel size, length, and complexity. The rate of clinical success did not differ between the groups. African-Americans experienced more in-hospital combined events of death and Q-wave myocardial infarction (p = 0.03). After propensity score adjustment, African-American race was not an independent predictor for in-hospital events. At 1 year, African-Americans had a slightly lower rate of target lesion revascularization and a 50% higher rate of death (9.8% vs. 6.4%, p <0.001), with a relative risk of 1.52 (95% confidence interval 1.22 to 1.89). In multivariate analysis, African-American race remained a significant predictor of increased 1-year mortality (hazard ratio 1.35, 95% confidence interval 1.06 to 1.71, p = 0.01). African-Americans undergoing angioplasty have more co-morbid baseline conditions than Caucasians. Despite similar clinical success, 1-year outcomes are impaired in African-Americans.
Collapse
Affiliation(s)
- Laurent Leborgne
- Cardiovascular Research Institute, Washington Hospital Center, Washington, DC 20010, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Kuchulakanti PK, Satler LF, Suddath WO, Pichard AD, Kent KM, Pakala R, Canos DA, Pinnow EE, Rha SW, Waksman R. Vascular complications following coronary intervention correlate with long-term cardiac events. Catheter Cardiovasc Interv 2004; 62:181-5. [PMID: 15170707 DOI: 10.1002/ccd.20057] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We aimed to study the consequences and late outcomes of patients who experienced peripheral vascular complications (PVCs) following percutaneous coronary interventions (PCI). A retrospective analysis of the medical records of 10,669 patients who underwent PCI and experienced PVC between 1995 and 2002 was conducted. One thousand ninety-six patients (10.27% of the study cohort) had PVC post-PCI. After PCI, patients with PVC had higher rates of in-hospital complications (P < 0.001) when compared to patients without PVC, including Q-wave myocardial infarction (MI; 1.2% vs. 0.3%), coronary artery bypass grafting (CABG; 3.8% vs. 0.6%), and death (4.0% vs. 1.0%). At 1-year follow-up, late complications of MI (37.4% vs. 25.4%), non-Q-wave MI (34.9% vs. 22.7%), death (12.9% vs. 5.9%), and CABG (5.7% vs. 4.5%) were higher (< 0.001) in patients with PVC compared to those without. Multivariate analysis identified PVC as a significant predictor of 1-year mortality (P = 0.045). This study underscores the need to make diligent efforts to minimize PVC and follow up these patients for future coronary events.
Collapse
|
17
|
Kinnaird TD, Stabile E, Mintz GS, Lee CW, Canos DA, Gevorkian N, Pinnow EE, Kent KM, Pichard AD, Satler LF, Weissman NJ, Lindsay J, Fuchs S. Incidence, predictors, and prognostic implications of bleeding and blood transfusion following percutaneous coronary interventions. Am J Cardiol 2003; 92:930-5. [PMID: 14556868 DOI: 10.1016/s0002-9149(03)00972-x] [Citation(s) in RCA: 350] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Bleeding related to percutaneous coronary intervention (PCI) occurs relatively frequently. We retrospectively investigated the incidence, predictors, and prognostic impact of periprocedural bleeding and transfusion in 10,974 patients who underwent PCI. Bleeding definitions were based on Thrombolysis In Myocardial Infarction (TIMI) criteria: (1) major bleeding (n = 588; 5.4%): if patients had a hemorrhagic stroke or if hematocrit decreased >15 points or by 10 to 15 points with clinical bleeding; (2) minor bleeding (n = 1,394; 12.7%): if hematocrit decreased <10 points with clinical bleeding or by 10 to 15 points without clinical bleeding; and (3) no bleeding (n = 8,992; 81.9%): if hematocrit decreased <10 points without clinical bleeding. Patients with major bleeding were older than patients with minor or no bleeding (67.8 +/- 11 vs 65.9 +/- 11 vs 63.6 +/- 11 years, respectively; p <0.001) and more often experienced intraprocedural complications, such as emergency use of an intra-aortic balloon pump (13.6% vs 6.5% vs 2.3%, respectively; p <0.001). Multivariate logistic regression analysis identified the use of an intra-aortic balloon pump (odds ratio [OR] 3.0, p <0.0001), procedural hypotension (OR 2.9, p <0.001), and age >80 years (OR 1.9 compared with age <50 years, p = 0.001) as the strongest predictors for major bleeding. Patients who had major bleeding had higher in-hospital and 1-year mortality compared with patients with minor or no bleeding. Bleeding was an independent predictor of in-hospital death. Thus, periprocedural major bleeding occurs relatively frequently and is associated with adverse outcomes. Patients >80 years of age who experience intraprocedural complications are at particularly high risk.
Collapse
Affiliation(s)
- Timothy D Kinnaird
- Cardiovascular Research Institute and Cardiac Catheterization Laboratory, Washington Hospital Center, Washington, DC 20010, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Wolfram R, Leborgne L, Cheneau E, Pinnow EE, Canos DA, Hellinga D, Satler LF, Pichard AD, Kent KM, Waksman R. Comparison of effectiveness and safety of three different antithrombotic regimens (bivalirudin, eptifibatide, and heparin) in preventing myocardial ischemia during percutaneous coronary intervention. Am J Cardiol 2003; 92:1080-3. [PMID: 14583359 DOI: 10.1016/j.amjcard.2003.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of this retrospective, observational analysis was to compare the efficacy and safety of 3 antithrombotic regimens: bivalirudin, eptifibatide plus heparin, and heparin alone, with emphasis on preventing interventional procedural creatinine kinase-MB fraction (CK-MB) release, and consequently, myocardial necrosis.
Collapse
Affiliation(s)
- Roswitha Wolfram
- Cardiovascular Research Institute, Division of Cardiology, Washington Cancer Center, Washington, DC, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Affiliation(s)
- Shadi M Hamwi
- Department of Cardiology, Washington Hospital Center, Washington, DC 20010, USA
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Lindsay J, Apple S, Pinnow EE, Gevorkian N, Gruberg L, Satler LF, Pichard AD, Kent KM, Suddath W, Waksman R. Percutaneous coronary intervention-associated nephropathy foreshadows increased risk of late adverse events in patients with normal baseline serum creatinine. Catheter Cardiovasc Interv 2003; 59:338-43. [PMID: 12822153 DOI: 10.1002/ccd.10534] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In patients with chronic renal insufficiency, further decline in renal function (DRF) after percutaneous coronary intervention (PCI) is accompanied not only by adverse in-hospital events but also by increased risk of mortality and myocardial infarction at 1 year. This analysis was undertaken to determine if patients with normal renal function who develop DRF after PCI have a comparable increase in risk of death and myocardial infarction at 1 year, and whether this risk is independent of in-hospital complications (death, myocardial infarction, urgent coronary artery bypass grafting). We performed a retrospective analysis of all patients from a single center who underwent successful PCI with no major in-hospital complications who had pre-PCI serum creatinine (SCr) </= 1.2 mg/dl and no history of renal insufficiency. One-year follow-up was obtained by mail or telephone. There were 5,967 consecutive patients who met the inclusion criteria. Of these, 208 (3.5%) developed DRF (an increase in SCr >/= 50% of baseline). They were more likely to be older, female, non-Caucasian, diabetic and/or hypertensive. They reported more prior cerebral or peripheral vascular events. They had undergone more complex PCI and were exposed to more radiographic contrast than the 96.5% who did not develop DRF. After adjustment for baseline variables, DRF remained an independent predictor of 1-year mortality, myocardial infarction, and target vessel revascularization. In patients without prior renal impairment, DRF post-PCI is rare but is associated with an increased risk of late adverse cardiac events similar to that in chronic renal insufficiency patients.
Collapse
Affiliation(s)
- Joseph Lindsay
- Department of Cardiology, Washington Hospital Center, Washington, D.C.,USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Castagna MT, Mintz GS, Kotani JI, Shah VM, Pinnow EE, Kent KM, Suddath WO, Waksman R, Satler LF, Berzingi CO, Pichard AD, Weissman NJ. Fixing chronic stent underexpansion is associated with a low rate of recurrence: An intravascular ultrasound analysis. J Am Coll Cardiol 2003. [DOI: 10.1016/s0735-1097(03)80031-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
22
|
Gruberg L, Weissman NJ, Pichard AD, Waksman R, Kent KM, Satler LF, Suddath WO, Pinnow EE, Gevorkian N, Lindsay J. Impact of renal function on morbidity and mortality after percutaneous aortocoronary saphenous vein graft intervention. Am Heart J 2003; 145:529-34. [PMID: 12660678 DOI: 10.1067/mhj.2003.121] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Percutaneous coronary intervention in patients with chronic renal insufficiency (CRI) and native coronary artery disease is often problematic, marred by increased morbidity and mortality rates and a high incidence of restenosis and revascularization. However, little is known about the effect of CRI in patients who have undergone prior coronary artery bypass graft surgery and then undergo saphenous vein graft (SVG) intervention. METHODS We analyzed the inhospital and 1-year outcomes of 1265 consecutive patients with normal renal function and varying degrees of renal insufficiency who underwent percutaneous SVG intervention and divided them into 4 groups on the basis of the calculated creatinine clearance (CrCl): group 1, CrCl > or =70 mL per minute (n = 626); group 2, CrCl 50 to 69 mL per minute (n = 357); group 3, CrCl 30 to 49 mL per minute (n = 228); and group 4, CrCl <30 mL per minute (n = 54). Patients undergoing dialysis replacement therapy were excluded from the study. RESULTS Patients with lower CrCl more often were older, female, had diabetes mellitus, and had worse left ventricular function. Angiographic baseline characteristics were comparable among the 4 groups. Overall immediate procedural success was similar for all groups. Patients with a low CrCl had significantly higher inhospital overall and cardiac mortality rates (P <.001), including a significantly higher incidence of myocardial infarction, vascular complications, pulmonary edema, and renal function deterioration. At 1-year follow-up, the overall mortality rates remained significantly higher in patients with decreased CrCl, with an incremental rise in overall mortality rate associated with lower renal function (P <.001). CONCLUSIONS This study suggests that renal function is a primary determinate of short- and long-term survival in patients undergoing percutaneous SVG intervention and that there is a clear relationship between CrCl and cardiovascular outcome.
Collapse
Affiliation(s)
- Luis Gruberg
- Division of Cardiology and Cardiovascular Research Institute, Washington Hospital Center, Washington, DC 20010, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Fuchs S, Stabile E, Kinnaird TD, Mintz GS, Gruberg L, Canos DA, Pinnow EE, Kornowski R, Suddath WO, Satler LF, Pichard AD, Kent KM, Weissman NJ. Stroke complicating percutaneous coronary interventions: incidence, predictors, and prognostic implications. Circulation 2002; 106:86-91. [PMID: 12093775 DOI: 10.1161/01.cir.0000020678.16325.e0] [Citation(s) in RCA: 166] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke associated with percutaneous coronary intervention (PCI) is an infrequent although devastating complication. We investigated the incidence, predictors, and prognostic impact of periprocedural stroke in unselected patients undergoing PCI. METHODS AND RESULTS A total of 9662 patients who underwent 12 407 PCIs between January 1990 and July 1999 were retrospectively studied. Stroke was diagnosed in 43 patients (0.38% of procedures). Patients with stroke were older (72+/-11 versus 64+/-11 years, P<0.001), had lower left ventricular ejection fraction (42+/-12 versus 46+/-13%, P=0.04) and more diabetes (39.5% versus 27.2%, P=0.07), and experienced a higher rate of intraprocedural complications necessitating emergency use of intra-aortic balloon pump (IABP) (23.3% versus 3.3%, P<0.001). In-hospital mortality (37.2% versus 1.1%, P<0.001) and 1-year mortality (56.1% versus 6.5%, P<0.001) were higher in patients with stroke. Compared with hemorrhagic stroke, patients with ischemic stroke had higher rate of in-hospital major adverse cardiac events (57.1% versus 25%, P=0.037). Multivariate logistic regression analysis identified emergency use of IABP as the strongest predictors for stroke (OR=9.6, CI 3.9 to 23.9, P<0.001), followed by prophylactic use of IABP (OR=5.1), age >80 years (OR=3.2, compared with age <50 years), and vein graft intervention (OR=2.7). CONCLUSIONS Stroke associated with contemporary PCI is associated with substantial increased mortality. Elderly patients who experience intraprocedural complications necessitating the use of IABP are at particularly high risk.
Collapse
Affiliation(s)
- Shmuel Fuchs
- Cardiovascular Research Institute and the Cardiac Catheterization Laboratories, Washington Hospital Center, Washington, DC 20010, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Gruberg L, Waksman R, Ajani AE, Kim HS, White RL, Pinnow EE, Satler LF, Pichard AD, Kent KM, Lindsay J. The effect of intracoronary radiation for the treatment of recurrent in-stent restenosis in patients with diabetes mellitus. J Am Coll Cardiol 2002; 39:1930-6. [PMID: 12084590 DOI: 10.1016/s0735-1097(02)01891-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The purpose of this study was to examine the effect of intracoronary radiation therapy (IRT) in diabetic patients with in-stent restenosis (ISR). BACKGROUND Diabetic patients are at an increased risk for restenosis, repeat revascularization procedures and late mortality after percutaneous coronary interventions and stenting. Intracoronary radiation therapy, utilizing both gamma and beta-emitters, has been shown to reduce the rate of ISR. METHODS The study group consisted of 749 consecutive patients with ISR who were treated with either IRT or placebo in randomized trials and registries at our center. Diabetic patients (252 radiation and 51 placebo) were compared with nondiabetic patients (371 radiation and 75 placebo). RESULTS In-hospital outcomes were similar between diabetic and nondiabetic patients treated with and without radiation. At six-month clinical and angiographic follow-up, there was a significant reduction in the binary restenosis (63.8% vs. 15.7%, p < 0.0001), target lesion revascularization (66.7% vs. 17.6%, p < 0.0001) and target vessel revascularization (TVR) (70.6% vs. 22.9%, p < 0.0001) rates in diabetic patients treated with radiation compared to placebo. Comparisons between the placebo arms detected a trend towards higher restenosis (63.8% vs. 48.4% p = 0.13) and TVR (70.6% vs. 56.0%, p = 0.14) in diabetic versus nondiabetic patients. In contrast, diabetic and nondiabetic patients treated with IRT experienced similar restenosis (15.6% vs. 10.7% p = 0.33) and TVR (22.9% vs. 28.2% p = 0.41) rates. CONCLUSIONS In diabetic patients with ISR, intracoronary radiation significantly reduced the recurrence of ISR compared to placebo. Additionally, similar rates of restenosis and revascularization procedures were achieved in irradiated diabetic and nondiabetic patients. In view of these results, IRT should be considered as a valuable therapeutic alternative in all diabetic patients with ISR.
Collapse
Affiliation(s)
- Luis Gruberg
- Cardiovascular Research Institute, Washington Hospital Center, Washington, DC 20010, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Maehara A, Mintz GS, Bui AB, Castagna MT, Walter OR, Pappas C, Pinnow EE, Pichard AD, Satler LF, Waksman R, Suddath WO, Laird JR, Kent KM, Weissman NJ. Incidence, morphology, angiographic findings, and outcomes of intramural hematomas after percutaneous coronary interventions: an intravascular ultrasound study. Circulation 2002; 105:2037-42. [PMID: 11980682 DOI: 10.1161/01.cir.0000015503.04751.bd] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intramural hematomas during percutaneous coronary intervention (PCI) have not been well studied. METHODS AND RESULTS We used intravascular ultrasound to determine the incidence, morphology, and clinical features of post-PCI intramural hematomas. In 905 patients with 1025 consecutive native coronary artery, non-in-stent restenosis lesions undergoing PCI, 72 hematomas were detected in 69 arteries in 68 patients. The incidence of intramural hematomas per artery was 6.7% (69 of 1025); 36% (26 of 72) involved the proximal reference artery, 18% (13 of 72) were confined to the lesion, and 46% (33 of 72) involved the distal reference artery. The entry site from the lumen into the hematoma was identified in 86% of hematomas (62 of 72) and had the appearance of a dissection into the media. Conversely, a re-entry site was identifiable in only 8% (6 of 72). The axial extension of the hematoma was distal in 63% and proximal in 37%. In 60% of the hematomas (42 of 72) the angiogram had the appearance of a dissection; in 11% (8 of 72), it appeared to be a new stenosis; and in 29% (22 of 72), no significant abnormality was detected. Non-Q-wave myocardial infarctions occurred in 26% of patients (17 of 65). In 3 patients, the creatine kinase-MB was not measured during the hospital stay. Repeat revascularization occurred in 2 patients in-hospital, 2 additional patients at 1 month, and 8 additional patients at 1 year. There were 3 sudden deaths at 1 year. CONCLUSIONS Intravascular ultrasound identified intramural hematomas after 6.7% of PCIs. The mechanism appeared to be a dissection into the media where blood accumulated because of a lack of re-entry. A third of ultrasound-identified hematomas showed no angiographic abnormalities. There was a high rate of non-Q-wave myocardial infarction, need for repeat revascularization, and sudden death in patients with hematomas.
Collapse
Affiliation(s)
- Akiko Maehara
- Intravascular Ultrasound Imaging and Cardiac Catheterization Laboratories, Cardiovascular Research Institute, Washington Hospital Center, Washington, DC 20010, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Waksman R, Ajani AE, White RL, Chan RC, Satler LF, Kent KM, Pichard AD, Pinnow EE, Bui AB, Ramee S, Teirstein P, Lindsay J. Intravascular gamma radiation for in-stent restenosis in saphenous-vein bypass grafts. N Engl J Med 2002; 346:1194-9. [PMID: 11961147 DOI: 10.1056/nejmoa012579] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intracoronary radiation therapy is effective in reducing the recurrence of in-stent stenosis in native coronary arteries. We examined the effects of intravascular gamma radiation in patients with in-stent restenosis of saphenous-vein bypass grafts. METHODS A total of 120 patients with in-stent restenosis in saphenous-vein grafts, the majority of whom had diffuse lesions, underwent balloon angioplasty, atherectomy, additional stenting, or a combination of these procedures. If the intervention was successful, the patients were randomly assigned in a double-blind fashion to intravascular treatment with a ribbon containing either iridium-192 or nonradioactive seeds. The prescribed dose, delivered at a distance of 2 mm from the source, was 14 to 15 Gy in vessels that were 2.5 to 4.0 mm in diameter and 18 Gy in vessels with a diameter that exceeded 4.0 mm. The primary end points were death from cardiac causes, Q-wave myocardial infarction, revascularization of the target vessel, and a composite of these events at 12 months. RESULTS Revascularization and radiation therapy were successfully accomplished in all patients. At six months, the restenosis rate was lower in the 60 patients assigned to the iridium-192 group than in the 60 assigned to the placebo group (21 percent vs. 44 percent, P=0.005). At 12 months, the rate of revascularization of the target lesion was 70 percent lower in the iridium-192 group than in the placebo group (17 percent vs. 57 percent, P<0.001), and the rate of major cardiac events was 49 percent lower (32 percent vs. 63 percent, P<0.001). CONCLUSIONS The results of our study support the use of gamma-radiation therapy for the treatment of in-stent restenosis in patients with bypass grafts.
Collapse
Affiliation(s)
- Ron Waksman
- Division of Cardiology, Washington Hospital Center and the Washington Cancer Institute, Washington, DC 20010, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Gruberg L, Silverman A, Pinnow EE, Suddath WO, Satler LF, Laird JR, Pichard AD, Kent KM, Lindsay J, Waksman R. Estrogen replacement therapy and morbidity and mortality after percutaneous coronary intervention. J Am Coll Cardiol 2002. [DOI: 10.1016/s0735-1097(02)80213-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
28
|
Gruberg L, Laird JR, Satier LF, Curry BH, Monsein LH, Langley D, Deible R, Pinnow EE, Lindsay J. Stent supported carotid artery angioplasty: the impact of renal function on the neurological outcome. J Am Coll Cardiol 2002. [DOI: 10.1016/s0735-1097(02)80290-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
29
|
Gruberg L, Weissman NJ, Waksman R, Fuchs S, Deible R, Pinnow EE, Ahmed LM, Kent KM, Pichard AD, Suddath WO, Satler LF, Lindsay J. The impact of obesity on the short-term and long-term outcomes after percutaneous coronary intervention: the obesity paradox? J Am Coll Cardiol 2002; 39:578-84. [PMID: 11849854 DOI: 10.1016/s0735-1097(01)01802-2] [Citation(s) in RCA: 482] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The purpose of this study was to assess the impact of body mass index (BMI) on the short- and long-term outcomes after percutaneous coronary intervention (PCI). BACKGROUND Obesity is associated with advanced coronary artery disease (CAD). However, the relation between BMI and outcome after PCI remains controversial. METHODS We studied 9,633 consecutive patients who underwent PCI between January 1994 and December 1999. Patients were divided into three groups according to BMI: normal, BMI between 18.5 and 24.9 (n = 1,923); overweight, BMI between 25 and 30 (n = 4,813); and obese, BMI >30 (n = 2,897). RESULTS Obese patients were significantly younger and had consistently worse baseline clinical characteristics than normal or overweight patients, with a higher incidence of hypertension, diabetes, hypercholesterolemia and smoking history (p < 0.0001). Despite similar angiographic success rates among the three groups, normal BMI patients had a higher incidence of major in-hospital complications, including cardiac death (p = 0.001). At one-year follow-up, overall mortality rates were significantly higher for normal BMI patients compared with overweight or obese patients (p < 0.0001). Myocardial infarction and revascularization rates did not differ among the three groups. By multivariate Cox regression analysis, diabetes, hypertension, age, BMI and left ventricular function were independent predictors of long-term mortality. CONCLUSIONS In patients with known CAD who undergo PCI, very lean patients (BMI <18.5) and those with BMI within the normal range are at the highest risk for in-hospital complications and cardiac death and for increased one-year mortality.
Collapse
Affiliation(s)
- Luis Gruberg
- Cardiac Catheterization Laboratory and the Cardiovascular Research Institute, Washington Hospital Center, Washington, DC 20010, USA.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Gruberg L, Weissman NJ, Waksman R, Laird JR, Pinnow EE, Wu H, Deible R, Kent KM, Pichard AD, Satler LF, Lindsay J. Comparison of outcomes after percutaneous coronary revascularization with stents in patients with and without mild chronic renal insufficiency. Am J Cardiol 2002; 89:54-7. [PMID: 11779523 DOI: 10.1016/s0002-9149(01)02163-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Luis Gruberg
- Cardiac Catheterization Laboratory and the Cardiovascular Research Institute, Washington Hospital Center, Washington, DC 20010, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Affiliation(s)
- U Iqbal
- Section of Cardiology, Washington Hospital Center, Washington, DC 20010, USA
| | | | | |
Collapse
|
32
|
Ajani AE, Waksman R, Kim HS, Satler LF, Pichard AD, Kent KM, Porrazzo M, White RL, Pinnow EE, Lindsay JR. Excimer laser coronary angioplasty and intracoronary radiation for in-stent restenosis: six-month angiographic and clinical outcomes. Cardiovasc Radiat Med 2001; 2:191-6. [PMID: 11786326 DOI: 10.1016/s1522-1865(01)00087-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate 6-month clinical and angiographic outcomes in patients treated with excimer laser coronary angioplasty (ELCA) and intracoronary radiation (ICR) for in-stent restenosis (ISR). METHODS A consecutive series of 175 patients with ISR treated with ELCA+ICR (gamma and beta emitters) were compared to 33 patients with ISR treated with ELCA alone. Baseline characteristics were similar between groups. ELCA+ICR and ELCA-alone patients had similar lesion lengths (25.0+/-12.0 vs. 24.0+/-16.8 mm, P=NS) in predominantly saphenous vein grafts (SVG, 38% vs. 42%, P=NS). RESULTS Procedural success was high (ELCA+ICR, 97.0% vs. ELCA alone, 98.5%, P=NS), with no perforations or acute vessel closures. ELCA+ICR therapy reduced target vessel revascularization (TVR; 27% vs. 64%, P<.0001) and major adverse cardiac events [MACE: death, myocardial infarction (MI), or TVR; 30% vs. 64%, P<.0001] compared to ELCA alone. Late loss was 0.66+/-0.90 mm in ELCA+ICR patients and 0.85+/-0.60 mm in ELCA-alone patients (P=NS). Angiographic binary restenosis (>50%) was significantly reduced with adjunctive ICR (28% vs. 54%, P=.014). CONCLUSION Radiation therapy with ELCA significantly reduces angiographic binary restenosis at 6 months in patients with diffuse ISR, driven predominantly by reduced percutaneous TVR.
Collapse
Affiliation(s)
- A E Ajani
- Catheterization Laboratories, Washington Hospital Center, Suite 4B-1, 110 Irving Street Northwest, Washington, DC 20010, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Abstract
The infrequency of adverse in-hospital events limits scorecarding individual angioplasty operators. We assessed 30-day events for this purpose. Thirty-nine operators performed 1,950 coronary interventions from 1 April to 30 September 1998. Thirty-day follow-up was obtained in 1,896 (97.2%), who form the basis for this analysis. We recorded 16 baseline variables and chose an endpoint of mortality or target vessel revascularization. The endpoint occurred in 103 (5.4%) patients by 30 days. Independent predictors were identified by multivariate modeling. The expected event rate for the set of patients treated by each operator was determined. Two operators had significantly more adverse events by 30 days than predicted and two others had an event rate approaching significance. Two of these four performed at least 60 procedures during the 6-month period. With 30-day events, operators whose complication rates exceed laboratory standards can be identified with achievable sample sizes. Volume alone does not appear to be sufficient assurance of quality outcomes.
Collapse
Affiliation(s)
- J Lindsay
- Section of Cardiology, the Washington Hospital Center, Washington, DC 20010, USA.
| | | | | |
Collapse
|
34
|
Abstract
OBJECTIVES To test one-month outcomes in a single center for their statistical power to corroborate conclusions derived from large multicenter databases. BACKGROUND Only with large, multicenter databases has it been possible to demonstrate more frequent occurrences of complications in patients treated by "low-volume operators." Critics feel that such analyses mask excellent performance by many "low-volume operators." METHODS In a high-volume cardiac catheterization laboratory in a large, nonuniversity teaching hospital, baseline clinical and angiographic characteristics were collected for a consecutive series of 1,029 patients treated by 37 percutaneous transluminal coronary intervention (PTCI) operators over a four-month period. One-month follow-up was obtained in 967 (94%) patients who form the basis for this analysis. RESULTS Only the group of operators performing <50 cases annually had a major adverse cardiac event (MACE) (death, myocardial infarction or symptom-driven revascularization) rate at one month significantly greater than predicted from baseline characteristics. (Observed rate: 15.1%, expected: 9.7%, 95% confidence interval [CI]: 4.7%, 14.6%.) The difference was driven by the significantly more frequent rate at which repeat revascularization was performed in patients treated by that group of operators (observed: 13.8%, expected: 7.1%, 95% CI: 2.8%, 11.4%). CONCLUSIONS As is true of analyses of large multicenter databases, lower volume operators as a group have less good outcomes than those performing more. The greater statistical power provided by one-month MACE rate offers advantages over the use of in-hospital complications for the analysis of operator performance.
Collapse
Affiliation(s)
- J Lindsay
- Section of Cardiology, The Washington Hospital Center, Washington, DC 20010, USA.
| | | | | |
Collapse
|
35
|
|
36
|
Abstract
After rigorous screening by means of registries and controlled trials, various atherectomy devices, excimer laser catheters, and endoluminal stents were approved for general clinical use. Few data are available describing their safety and effectiveness after approval. This analysis was undertaken to assess the impact on patient outcomes of the unrestricted clinical application of new transcatheter devices for coronary angioplasty. Thirty-six cardiologists performed 3,113 transcatheter procedures during 1995. Each chose the transcatheter modality best suited to the clinical and angiographic features of the patient. Baseline clinical and angiographic data and initial outcome were recorded by cardiac catheterization laboratory personnel. In-hospital events were obtained by independent chart review. Balloon angioplasty alone was employed in 1,089 (35.0%) patients. A stent was deployed after balloon angioplasty in 1,029 (33.1%) patients. An atherectomy or laser device was used without stent support in 631 (20.3%) patients, and stent support was added in an additional 364 (11.7%) patients. In all three new device categories the angiographic success (final luminal narrowing <50%) rate was better than in balloon angioplasty for type-C lesions and for chronic occlusions. The frequency of adverse events in the aggregate was not increased with device use, but the frequency of coronary artery bypass surgery was reduced with stent use. The frequency of non-Q-wave myocardial infarction was greater with devices than with balloon angioplasty alone. After adjustment for the differences in baseline clinical and angiographic variables by means of multivariate analysis, each of the three new device categories was independently associated with an increased chance of angiographic and procedural success compared to balloon angioplasty. The availability of new transcatheter devices for clinical practice enhances patient outcomes during hospitalization for the procedure.
Collapse
Affiliation(s)
- J Lindsay
- Section of Cardiology, Washington Hospital Center, DC 20010, USA.
| | | | | |
Collapse
|
37
|
Abstract
Electrocardiograms were recorded at baseline and regular intervals in 53 patients with myotonic dystrophy who were followed for a mean of 6.3 +/- 4.0 years. Patients with cardiac events had a significantly prolonged PR interval (p <0.001), a later age of onset of neuromuscular symptoms (p <0.05), and were older (p <0.005).
Collapse
Affiliation(s)
- J A Colleran
- Department of Neurology, Georgetown University Medical Center, Washington, D.C., USA
| | | | | | | | | |
Collapse
|
38
|
Lindsay J, Hong MK, Pinnow EE, Pichard AD. Effects of endoluminal coronary stents on the frequency of coronary artery bypass grafting after unsuccessful percutaneous transluminal coronary vascularization. Am J Cardiol 1996; 77:647-9. [PMID: 8610620 DOI: 10.1016/s0002-9149(97)89324-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Coronary artery stents have been rapidly incorporated into clinical practice so that they are currently deployed in nearly 50% of all patients undergoing angioplasty procedures in a busy laboratory. A decline in the frequency of coronary bypass surgery for unsuccessful angioplasty is associated with this change in practice-a decline in the use of atherectomy devices and no increase in length of stay for angioplasty patients.
Collapse
Affiliation(s)
- J Lindsay
- Section of Cardiology, The Washington Hospital Center, Washington D.C. 20010, USA
| | | | | | | |
Collapse
|
39
|
Flood RD, Lindsay J, Pinnow EE. Elective percutaneous transluminal coronary angioplasty after acute myocardial infarction: is later better? Am J Cardiol 1995; 76:966-7. [PMID: 7484841 DOI: 10.1016/s0002-9149(99)80272-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- R D Flood
- Section of Cardiology, Washington Hospital Center, D.C. 20010, USA
| | | | | |
Collapse
|
40
|
MESH Headings
- Angina, Unstable/complications
- Angina, Unstable/mortality
- Angina, Unstable/therapy
- Angioplasty, Balloon, Coronary/adverse effects
- Angioplasty, Balloon, Coronary/mortality
- Angioplasty, Balloon, Coronary/statistics & numerical data
- Coronary Disease/complications
- Coronary Disease/mortality
- Coronary Disease/therapy
- Humans
- Outcome and Process Assessment, Health Care/statistics & numerical data
Collapse
|
41
|
Abstract
Although successful dilatation of a target lesion by means of percutaneous transluminal coronary angioplasty (PTCA) can be attained as frequently in elderly as in younger patients, elderly patients have a higher risk of complications. Furthermore, cohorts of patients older than 75 years and undergoing PTCA include more women and more cases of unstable angina, factors that increase the risk of complications. Included in this analysis of 3199 PTCAs performed between January 1991 and September 1992 were 474 (14.8%) patients who were > or = 75 years old. Age was an independent risk factor for death, acute myocardial infarction, need for transfusion, and need for arterial repair after PTCA. The frequency of successful dilatation of individual lesions, emergency coronary bypass surgery, or repeated PTCA of the same lesion was not related to age. In previous studies no association has been demonstrated between age and increased risk of in-hospital reclosure. The presence of more severe coronary disease and of the greater frequency of coexisting morbid conditions makes elderly patients less able to tolerate unsuccessful or complicated PTCA.
Collapse
Affiliation(s)
- J Lindsay
- Section of Cardiology, Washington Hospital Center, Washington, DC 20010
| | | | | | | | | |
Collapse
|
42
|
Lindsay J, Pinnow EE, Reddy VM, Pichard AD. Discordance in the predictors of mortality vs. those of ischemic complications following transcatheter coronary intervention. Cathet Cardiovasc Diagn 1994; 32:312-8. [PMID: 7987909 DOI: 10.1002/ccd.1810320404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Outcomes of percutaneous transluminal coronary angioplasty (PTCA) depend upon the skill of the angioplasty team and on the characteristics of the patient population. Comparisons of outcomes from different laboratories must take into account the latter. A discordance may exist between the baseline predictors of death in hospital following PTCA and those for periprocedural ischemia. Baseline clinical and procedural characteristics of 3,725 patients who underwent PTCA during 1991 and 1992 were compared with complications by multivariate analysis. The age of the patient and the occurrence of an MI within the previous 30 days were the most powerful independent predictors of death. Ischemic complications were not independently associated with these factors. Emergency CABG was associated independently with target lesion complexity and abrupt reclosure, with unstable angina or attempted saphenous vein graft dilatation. Thus, mortality may more directly reflect baseline clinical characteristics than the skill of operators in avoiding ischemic complications.
Collapse
Affiliation(s)
- J Lindsay
- Section of Cardiology, Washington Hospital Center, Washington, DC 20010
| | | | | | | |
Collapse
|
43
|
Lindsay J, Reddy VM, Pinnow EE, Pichard AD. Complications of percutaneous transluminal coronary angioplasty in patients convalescing from acute myocardial infarction. Am J Cardiol 1994; 73:1214-5. [PMID: 8203342 DOI: 10.1016/0002-9149(94)90185-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- J Lindsay
- Section of Cardiology, Washington Hospital Center, Washington, D.C
| | | | | | | |
Collapse
|